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Attachment disorder is a term based on the psychological theories that

normal mother-child attachment forms in the first two years of life; and
if a normal attachment is not formed during the first two to three years, attachment can be induced later.

Attachment disorder is a term that is often seen in the research literature (O'Connor & Zeanah) but which is much broader than the clinical diagnosis of Reactive attachment disorder, which is described in the Diagnostic & Statistical Manual, 4th Edition, Technical Revision, of the American Psychiatric Association.

This theory ( Attachment Theory ) is used, for example, to explain the behavioral difficulties of children who have experienced chronic early maltreatment, such as foster and adopted children.

Attachment therapy is a broad term with no generally agreed-upon meaning, as it covers a wide variety of interventions. As such, some believe the term has lost utility.

Attachment theory was developed by John Bowlby in the 1940s and 1950s and is the leading theory used in the fields of Infant Mental Health, Child Development, and related fields (Zeanah, C., 1999). It is a well researched theory that describes how the attachment relationship develops, why it is crucial to later healthy development, and what are the effects of early maltreatment or other disruptions in this process.

Reputable approaches to treatment based on theory and research evidence include Theraplay and Dyadic Developmental Psychotherapy. However, the use of coercive interventions has no basis in theory and is not supported by any reputable professional organization, including The Association for The Treatment and Training in the Attachment of Children, APSAC, APA, NASW, or AMA. Neither Theraplay nor Dyadic Developmental Psychotherapy use coercive interventions and are in full compliance with the above referenced standards.

Signs of attachment problems

Attachment is fundamental to healthy development, normal personality, and the capacity to form healthy and authentic emotional relationships. How can one determine whether a child has attachment issues that require attention? What is normal behavior, and what are the signs of attachment issues? When adopting an infant, will attachment problems develop? These and other related questions are often at the forefront of adoptive parents’ minds.

Attachment is the base of emotional health, social relationships, and one's worldview (Zeanah, C., 1993). The ability to trust and form reciprocal relationships affects the emotional health, security, and safety of the child, as well as the child's development and future inter-personal relationships. The ability to regulate emotions, have a conscience, and experience empathy all require secure attachment. Healthy brain development is built on a secure attachment relationship.

Children who are adopted after the age of six months are at risk for attachment problems. Normal attachment develops during the child's first two to three years of life. Problems with the mother-child relationship during that time, orphanage experience, or breaks in the consistent caregiver-child relationship interfere with the normal development of a healthy and secure attachment. There are wide ranges of attachment difficulties that result in varying degrees of emotional disturbance in the child. One thing is certain; if an infant's needs are not met consistently, in a loving, nurturing way, attachment will not occur normally and this underlying problem will manifest itself in a variety of symptoms.

When the attachment-cycle is undermined and the child’s needs are not met, and normal socializing shame is not resolved, mistrust begins to define the perspective of the child and attachment problems result. The cycle can become undermined or broken for many reasons:

Multiple disruptions in care giving
Post-partum depression causing an emotionally unavailable mother
Hospitalization of the child causing separation from the parent and/or unrelieved pain. For example, stays in a NICU or repeated hospitalizations during infancy.
Parents who have experienced their own relational trauma, leading to neglect, abuse (physical/sexual/verbal), or inappropriate parental responses not leading to a secure/predictable relationship
Genetic factors
Pervasive developmental disorders
Caregivers whose own needs are not met, leading to overload and lack of awareness of the infants needs

The child may develop basic mistrust (Erikson), impeding effective attachment behavior. The developmental stages following these first three years continue to be distorted and/or retarded, and common symptoms emerge. It is very important to realize that when one is trying to parent a child with attachment difficulties one must focus on the cause of the behaviors and not on the symptoms or surface behaviors. Furthermore, the following behaviors can be indicators of a variety of problems. A child exhibiting several of these behaviors should receive a comprehensive evaluation by a licensed mental health professional to determine the cause of these symptoms. Many of these symptoms can be seen in children who have experienced complex trauma , attachment difficulties and other issues.

Superficially engaging and charming behavior, phoniness
Avoidance of eye contact
Indiscriminate affection with strangers
Lack of affection in a reciprocal manner
Destructiveness to self, others, and material things
Cruelty to animals
Crazy lying (lying in the face of the obvious)
Poor impulse control
Learning lags
Lack of cause/effect thinking
Lack of conscience
Abnormal eating patterns
Poor peer relationships
Preoccupation with fire and/or gore
Persistent nonsense questions and chatter indicating a need to control
Inappropriate clinginess and demandingness
Inappropriate sexuality

It is important to get a thorough evaluation as one symptom can have many causes. There are a variety of evidence-based methods to assess a child's pattern and style of attachment such as the Strange situation developed by Mary Ainsworth and a variety of narrative methods. Among adults, the Adult Attachment Interview is a frequently used research method.

Causes

What are the underlying causes of these various symptoms? The cause is some break in the early attachment relationship that results in difficulties trusting others . The child experiences a fear of close authentic emotional relationships because early maltreatment or other difficulties has "taught" the child that adults are not trust worthy and that the child is unloved and unlovable. Fundamentally, the cause is a developmental delay. The child may be chronologically six, ten, or fifteen, but developmentally these children are much younger. It is often useful to consider, "at what age would this behavior be normal?" Frequently one may find that the child’s behavior would be normal if the child were of a younger age.

Chronic Maltreatment (abuse or neglect) or other disruptions to the normal attachment relationship cause :

Fear of intimacy
Overwhelming feelings of shame (not guilt... shame causes a person to want to hide and not be seen. So, for example, some children’s chronic lying can be seen as a manifestation of this pervasive sense of shame. A lie is then another way to hide.)
Chronic feelings of being unloved
Chronic feelings of being unlovable
A distorted view of self, other, and relationships based on past maltreatment
Lack of trust
Feeling that nothing the child does can make a difference; hence, low motivation and poor academic performance
A core sense of being Bad
Difficulty asking for help
Difficulty relying on others in a cooperative and collaborative manner

How can the difference between a child who "looks" attached and a child who really is making a healthy, secure attachment be distinguished? This question becomes important for adoptive families because some adopted children will form an almost immediate dependency bond to their adoptive parents. To mistake this as secure and healthy attachment can lead to many problems down the road. Just because a child calls someone "Mom" or "Dad," snuggles, cuddles, and says, "I love you," does not mean that the child is attached or even attaching. Saying, "I love you," and knowing what that really feels like, can be two different things. Attachment is a process. It takes time. The key to its formation is trust, and trust becomes secure only after repeated testing. Generally attachment develops during the first two to three years of life (Bowlby 1988).

Older adopted children (see Adoption article for additional details.) need time to make adjustments to their new surroundings. They need to become familiar with their caregivers, friends, relatives, neighbors, teachers, and others with whom they will have repeated contact. They need to learn the ins and outs of new household routines and adapt to living in a new physical environment. Some children have cultural or language hurdles to overcome. Until most of these tasks have been accomplished, they may not be able to relax enough to allow the work of attachment to begin. In the meantime, behavioral problems related to insecurity and lack of attachment, as well as to other events in the child's past, may start to surface. Some start to get labels, like "manipulative," "superficial," or "sneaky." On the inside, this child is filled with anxiety, fear, grief, loss, and often a profound sense of being bad, defective, and unlovable. The child has not developed the self-esteem that comes with feeling like a valued, contributing member of a family. The child cares little about pleasing others since his relationships with them are quite superficial.

When are problems first apparent? Children who have experienced physical or sexual abuse, physical or psychological neglect, or orphanage life will begin to show difficulties as young as six-months of age . For example, the signs of difficulties for an infant include the following:

Weak crying response or rageful and/or constant whining; inability to be comforted
Tactile defensiveness
Poor clinging and extreme resistance to cuddling: seems stiff as a board
Poor sucking response
Poor eye contact, lack of tracking
No reciprocal smile response
Indifference to others
Failure to respond with recognition to parents
Delayed physical motor skill development milestones (creeping, crawling, sitting, etc.)
Flaccidity

Subtle signs of attachment problems

What are the subtle signs of attachment issues?

Sensitivity to rejection and to disruptions in the normally attuned connection between mother and child
Avoiding comfort when the child’s feelings are hurt, although the child will turn to the parent for comfort when physically hurt
Difficulty discussing angry feelings or hurt feelings
Over-valuing looks, appearances, and clothes
Sleep disturbances, not wanting to sleep alone
Precocious independence - a level of independence that is more frequently seen in slightly older children
Reticence and anxiety about changes
Picking at scabs and sores
Secretiveness
Difficulty tolerating correction or criticism

Internationally adopted children experience at least two significant changes during the first few months of life that can have a profound impact on later development and security. Birth mother to orphanage or foster care and then orphanage to adoptive home are two transitions. It is known from extensive research that prenatal, post-natal, and subsequent experiences create lasting impressions on a child. During the first few minutes, days, and weeks of life, the infant clearly recognizes the birth mother’s voice, smell, and taste. Changes in caregivers are disruptive. The new caregivers look different, smell different, sound different, taste different. In the orphanage there are often many care givers but no one special caregiver. Adoption brings with it a whole new, strange, and initially frightening world. These moves and disruptions have profound effects on a child's emotional, interpersonal, cognitive, and behavioral development. The longer a child is in alternate care, the more these subtle signs become pervasive.

There are effective ways for a parent to help his or her child. Parents and the right parenting are vital to preventing subtle signs from becoming anything more than sensitivities. Parenting consistently with clear and firm limits is essential. Discipline should be enforced with an attitude of sensitive and responsive empathy, acceptance, curiosity, love, and playfulness. This provides the most healing and protective way to correct a child.

These sensitivities do not constitute a mental illness or Reactive attachment disorder. They are subtle signs of attachment sensitivities. So, what can be done?

First, the most important thing one can do is maintain an attuned, emotionally close, and positive relationship with the child even when the child is being nasty or pushing buttons. It is at those times that the child most needs to feel loved and loveable, even if the behavior is unacceptable. First, a connection with the child must be created, and then the child must be disciplined.

Second, bringing the child in close is better than allowing the child to be alone or isolate him or her self.

Third, talking for the child is required - putting words to what the child is feeling. This allows the child to feel understood by the parent, maintains a connection, and helps assuage the fear of rejection and abandonment. It also helps the child become self-aware, models verbal behavior, and facilitates a sense of emotional attunement between parent and child.

Fourth, food shouldn't be made a battle. A child who steals food or hoards food usually has sound emotional reasons for this. Providing the child with food so that the child experiences the parent as provider is often the solution. Putting a bowl of fruit (which is kept filled) in the child’s room, or providing the child with a fanny pack and keeping it stocked with snacks might be useful, ending hoarding and stealing of food.

Fifth, for the child who is overly independent, doing for the child and not encouraging precocious independence is helpful. So, making a game of brushing the six-year-old’s teeth, dressing the seven-year-old, or playing at feeding a nine-year-old, are all ways to demonstrate that the parent will care for the child. Keeping it playful and light allows the child to experience what the child needs and helps eliminate hurtful battles.

Sixth, use Time-In rather than Time-Out. When the child is becoming dysregulated, they need the parents to regulate their emotions. They do that by reflecting the child’s emotions back to the child: putting into words what they think the child may be feeling. In this manner the parents demonstrate that they can accept what the child is feeling, that feelings can be tolerated and discussed, even if the behavior will be disciplined at a later time. Remember: first connect with the child, then discipline.

Seventh, reducing shame. Shaming parenting methods and interactions that might be harsh or punitive should be avoided. If the child is already experiencing too much shame, increasing that will only be destructive to the child and the relationship with the parents. The parents set the emotional tone for the relationship, so keeping things positive is important. So, as an example, a seven year old has just screamed at the parent, "I hate you," because he or she said that it's time to go to bed. One could start by reflecting the child’s feelings back to the child as one walks the child to bed with one's arm around the child, "Boy, you are really mad that you have to go to bed now." "You sure don’t want to go to bed now. I wonder what you think is making me send you to bed now? … Maybe you just think I’m being mean?" Through this sort of dialogue, the caregiver is demonstrating acceptance of the child's feelings and interest in the child's thinking and feeling. The parent is showing the child how to reflect on inner life. The model suggested for parents is to create a healing PLACE (being Playful, Loving, Accepting, Curious, and Empathic) (Hughes, 2003).

In conclusion, these subtle signs are important reminders that the children have ongoing sensitivities that must be addressed by the parents. Responsive and sensitive communication is essential. Attachment is a function of reciprocal communication; attachment does not reside in the child alone. It is very important for the parent to manage and facilitate this attuned connection within a framework of clear limits and boundaries, natural consequences, and firm loving discipline..

Treatment

There are a variety of evidence-based and effective prevention programs and treatment approaches for attachment disorder. Attachment theory is the basis for these and other treatment approaches. Several evidence-based and effective treatments are based on attachment theory including Theraplay and Dyadic Developmental Psychotherapy. Nearly all mainstream programs for the prevention and treatment of disorders of attachment use attachment theory. For example, the Circle of Security Program, (Dr. Robert Marvin, University of VA) is one such early intervention program with demonstrated effectiveness. Dr. Marvin and Dr. Siegel (University of California) both also endorse Dyadic Developmental Psychotherapy. Other promising treatment methods include the Circle of Security Program of Dr. Robert Marvin at the University of Virginia, Developmental, Individual-difference, Relationship-based therapy (DIR or Floor Time) by Stanley Greenspan. This treatment is consistent with the general principles for the treatment of trama (Briere & Scott, 2006).

Dyadic developmental psychotherapy (Hughes, 2004) is an evidence-based ("Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005) treatment approach for the treatment of attachment disorder and reactive attachment disorder. Children who have experienced pervasive and extensive trauma, neglect, loss, and/or other dysregulating experiences can benefit from this treatment. Dyadic Developmental Psychotherapy is based on principles derived from Attachment theory and Research; see the work of Bowlby. The treatment meets the standards of the American Professional Society on Child Abuse, The American Academy of Child Psychiatry, American Psychological Association, American Psychiatric Association, National Association of Social Workers, and various other groups' standards for the evaluation and treatment of children and adolescents. This is a non-coercive treatment.

Attachment therapy is a term with little or no agreed upon meaning. It is not a term that is used in generally accepted texts on psychotherapy. Components of "attachment therapy" have been disapproved by a task force of the American Professional Society on Abuse of children (Chaffin et al.,2006, PMID 16382093). However, the Circle of Security Program, Dyadic developmental psychotherapy, Developmental, Individual-difference, Relationship-based therapy (DIR or Floor Time) by Stanley Greenspan, and Theraplay are not considered controversal and meet the standards of the American Professional Society on Abuse of Children, as well as various other professional association standards for practice.

v t e Attachment theory
Theory	Affectional bond Attachment in adults Attachment in children Attachment disorder Attachment and health Attachment measures Attachment theory Dynamic-maturational model of attachment and adaptation Fathers as attachment figures Human bonding Maternal deprivation Object relations theory Reactive attachment disorder
Notable theorists	Mary Ainsworth William E. Blatz John Bowlby Patricia McKinsey Crittenden Erik Erikson Sigmund Freud Harry Harlow Jerome Kagan Melanie Klein Konrad Lorenz Mary Main René Spitz Nikolaas Tinbergen
Controversy	Attachment parenting Attachment therapy Candace Newmaker
Clinical applications	Attachment-based therapy (children) Attachment-based psychotherapy Dyadic developmental psychotherapy
Others	History of attachment theory

References

O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244.
Bowlby, J., (1988), A Secure Base, Basic Books, NY
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et. al., (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.
Bowlby, J., (1988), A Secure Base, Basic Books, NY
Becker-Weidman, A., & Shell, D., (2005), Creating Capacity For Attachment, Wood 'N' Barnes, Oklahoma City, OK
Brodzinsky, D., Schechter, M., & Marantz, R., (1992), Being Adopted, NY, Doubleday.
Hughes, D., (2006) Building the Bonds of Attachment, 2nd Edition, Norton, NY.
Holmes, J., The Search for the Secure Base, (2001), Brunner-Routledge, Philadelphia, PA.
Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
^ Becker-Weidman, A., (2006). Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006.
Briere, J., Scott,C.,(2006), Principles of Trauma Therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage.

Additional Reading and References

Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
Handbook of Infant Mental Health, edited by Charles Zeanah, MD, Guilford Press, 1993, NY.
Handbook of Attachment: Theory, Research, and Clinical Applications, edited by Jude Cassidy, Ph.D., & Phillip Shaver, Ph.D, Guilford Press, NY (1999).
Building the Bonds of Attachment, 2nd. Edition by Daniel Hughes, Ph.D., Guilford Press, 2006.
"Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005.
Creating Capacity For Attachment, (Eds.) Arthur Becker-Weidman, Ph.D., and Deborah Shell, MA, Wood 'N' Barnes, OK: 2005.ISBN 1-885473-72-9
O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
Hughes, Daniel, (1999) Building the Bonds of Attachment, NY: Guilford Press.
Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279.
Holmes, J., The Search for the Secure Base, (2001), Brunner-Routledge, Philadelphia, PA.
Bowlby, J., A Secure Base, (1988), Basic Boosk, NY.
Briere, J., and Scott, C., (2006) Principles of Trauma Therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage.